North Carolina Psychiatric Association September 27, 2018 CBASP Workshop Rationale, Techniques and Goals of the CBASP System Jim McCullough Rosie McCullough 1
Dysthymia Major Depression North Carolina Psychiatric Association September 27, 2018 DSM-5 Persistent Depressive Disorder (PDD) Psychopathology Graphing the Clinical Course Normal Mood Baseline (>2 years) Dysfunctional Developmental History JP McCullough, et al. (2016). Introducing a clinical-course graphing scale for DSM-5 Mood Disorders. American J of Psychotherapy, 70, 383-391. 2
DSM-5 Persistent Depressive Disorder Psychopathology Jordan B. Peterson : 12 Rules For Life: An Antidote To Chaos (12 disk set). Brilliant insights, but flawed when it comes to psychopathology assumptions. *Not everyone can take responsibility for his/her life! An assumption you may not be aware of: Early trauma & abuse may produce a cognitive-emotional maturational retardation & train-wreck (adults who function like 4-7 year old children; has nothing to do with IQ). René Spitz: marasmus children [non-responsive] Jean Piaget: paroxysms [cognitive disorganization] JP McCullough, Jr.: cognitive-emotive retardation [adult primitive thinking: preoperational functioning] 3
DSM-5 Persistent Depressive Disorder Psychopathology Early-onset Persistent Depressive Disorder Etiology: Traditional Abuse Constructs Rape Physical Abuse/Bullying Parental Abandonment Sexual Abuse Maturational Emotional Deprivation Retardation Physical Deprivation Etiology: Psychological Insults Frequent Negative Comments Predictive Negative Comments Emotional Abandonment/Threat of Accusatory Negative Comments 4
North Carolina Psychiatric Association September 27, 2018 DSM-5 Persistent Depressive Disorder Psychopathology Maturational Retardation Adult Preoperational Functioning (Jean Piaget (1924): Development of The Child) 5
Dysfunctional Early-onset Histories (Developmental Disruptions) Schramm, et al. (2011). J Affective Disorders Patient 1: Twenty-one year-old female reporting extreme sexual abuse and physically beaten from the age of 5-11 years by a stepfather. She reported that he screamed at her and threw her favorite stuffed animals in the trash can. She can recall him saying to her: I will be your first sexual partner as soon as you turn 12. The mother never protected the patient from the stepfather. Patient 2: Female (23 years) with severe-to-extreme emotional neglect and abuse coupled with physical and sexual abuse. The mother often took her in a car while she made love to other male friends. Patient 3: Female (34 years) with a history of severe-to-extreme physical and emotional abuse as well as neglect. Patient worked hard on the farm as a young child and was often physically beaten by her father. She described her life in terms of being one in which she had never experienced a decent human being. 6
Developmental Disruption (J Affective Disorders) Patient 4: Female (27 years) who reported severe-to-extreme sexual and emotional abuse and neglect. She began treatment with a significant body odor that was addressed successfully early in treatment. Her mother made it clear that she never wanted her, and she ignored and ridiculed the patient throughout the time she remained at home. The patient also reported a history where her biological father sexually abused her. Patient 5: Male (58 years old). The patient rated moderate emotional and physical abuse. His father was the only loving and stable person he could recall in his life, and the father died when the patient was seven years old. The mother never played with him and no one in the family was allowed to speak about the father or the reason for his death. The patient refused to go to school at age 8 and was subsequently put in a boarding school. He related he was often beaten by his boarding school teacher. He recalled wanting to die at age 11. Patient 6: Male (23years old), moderate-range emotional abuse. Father died while patient was a child and left the family in a chaotic state. Father was French, mother was Polish and they never adapted to living in Germany. Patient evinced antisocial behavior as a child (e.g., stealing, etc.). 7
Conclusion All of the above patients were once young children. When developing children are overwhelmed by the dangers of an abusive or neglectful home life, normal growth is thwarted because one s energies and behavior are directed towards surviving the hell of the family and not growth (Drotar & Sturm, 1991; Money, 1992; Money, Annecillo, & Hutchinson, 1985; Vander Molen, 2010). McCullough (2000, 2006) writes that among many adult early-onset patients, maturational stunting of growth or said another way, a failure to mature cognitively and emotionally is often painfully evident in the way the patients talk and behave. Reviewing the ten abbreviated abuse histories makes it easier to understand why early-onset chronically depressed individuals present with a pervasive interpersonal fear of others. As stated above, these fears conjoined with a generalized interpersonal avoidance pattern maintain the preoperational, intra-personal functioning of the chronically depressed adult. 8
North Carolina Psychiatric Association DSM-5 Persistent Depressive Disorder Psychopathology Most early-onset chronic adult patients do NOT think or emote the way you do. He or she functions on a level that mimics a very young child: I ve described it as a preoperational adult whose cognitive-emotive maturational level in the interpersonal arena remains under-developed. These patients functioning does not reflect a defective IQ (McCullough, 2000, 2006). Early-onset Chronic Preoperational Functioning Characteristics Pre-logical functioning (we overestimate their logical capacity) Reality is the way it is because I believe it absence of formal/abstractive operational reality testing Monologue speech (they don t talk with us or with others, they talk at us: Bi-directional speech/empathy is absent) Ego-centric (all roads leads to the patient) you don t exist for the patient (in any informing way that could change behavior) Global thinker when it comes to problems (always, everyone, forever, never, nothing, etc.) 9
Emotional-Fear Behavioral Dilemma of Preoperational Patient (Pavlovian Respondent: Emotion) Toxic Stimulus Cue Learning (UCS): Significant Others Reinforcer (UCR): Fear *(OS: Generalized Cues): People Situations (Skinnerian Operant: Behavior) Interpersonal Fear-Avoidance Behavior (R)! (Mark E. Bouton, 2007. Learning and Behavior: A Contemporary Synthesis) *OS: Occasion Setters 10 10
What s The Patient Afraid Of? 11
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Two Types of Chronic Patients & Therapist Strategy * The Actively Abused Patient (physically, verbally and/or non-verbally) requires the Therapist to slow down, hold back, tread lightly, and to be aware of the pace of the patient while doing CBASP Work [TH: If I have a relationship with Dr. Klein, then he will hurt/reject me. ] * The Emotionally Deprived or Physically Deprived Patient requires the Therapist to be more forthcoming, to be more active and to extend oneself more toward the patient while making sure one is walking with the patient. [TH: If I have a relationship with Dr. Schramm, then whatever I do will not matter to her/she will not care. ] 16
CBASP Goal: Teach the Patient a Pervasive Interpersonal Approach Style of Living [Goal of CBASP Treatment] From this (P): Person Therapist (one-person functioning) To this (P x E): Patient Therapist (two-person functioning) 17 17
How Is This Achieved in CBASP? 18
Successful Discrimination [SOs vs. Therapist] This is the way It WAS THEN with Significant Others Fearful Unsafe Unchanging Hopeless Helpless Interpersonal Avoidance! This is the way it IS NOW with My Therapist: Safe Helpful Hopeful Empowering Interpersonal Approach! Felt Interpersonal Safety Achieved! (Goal I of CBASP) 19
North Carolina Psychiatric Association September 27, 2018 DSM-5 Persistent Depressive Disorder Psychopathology Two Major Goals of Cognitive Behavioral Analysis System of Psychotherapy (CBASP): I) Creation of Dyadic Safety between Clinician & Patient II) Perceptual Connection between patient s behavior and consequences (perceived functionality) 20
North Carolina Psychiatric Association September 27, 2018 AVAILABLE CBASP BOOKS 1) McCullough, Jr., J.P. (2000).Treatment for Chronic Depression: CBASP. New York: Guilford Press. 2) McCullough, Jr., J.P. (2006). Treating Chronic Depression with Disciplined Personal Involvement: CBASP. New York: Springer. 3) McCullough, Jr., J.P., Schramm, E. & Penberthy, JK (2015). CBASP as a Distinctive Treatment for Persistent Depressive Disorder: Distinctive Feature Series. London: Routledge Press. <www.cbasp.org> 21 21